Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis.

BACKGROUND: In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. METHODS: We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. RESULTS: Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). CONCLUSION: Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

Supermicrosurgery: Principles and applications.

Supermicrosurgery is defined as microsurgery in less than 0.8 mm vessels. It is an evolved form of microsurgery but with the same principle: (1) enhanced working environment including microscopes and finer instruments; (2) detailed preoperative evaluation and planning; (3) supermicrosurgical technique; and (4) postoperative care. Supermicrosurgery now provides reconstructive solutions to address lymphedema, distal finger amputations, allows minimal invasive reconstruction using a perforator to perforator approach, and will eventually allow targeted customized reconstruction.

Cumulative Experience in Lymphovenous Anastomosis for Lymphedema Treatment: The Learning Curve Effect on the Overall Outcome.

BACKGROUND: The lymphovenous anastomosis (LVA) has become one of the treatment options for lymphedema. However, it is regarded as a difficult surgery that many young microsurgeons are reluctant to try. This report investigates the learning curve in regard to symptom improvement. METHODS: This is a retrospective analysis performed in 33 consecutive lymphedema patients (38 extremities) who underwent only LVAs from August 2010 to February 2016. Surgical outcomes in regard to surgeon's experience were evaluated. The surgeons experience was divided into three groups: early group with less than 2 years, moderate with 2 to 4 years, and mature group with more than 4 years of experience. RESULTS: A total of 31 limbs (8/8 in upper extremity and 23/30 in lower extremity) showed improvement. When we compare volume change and recurrence of cellulitis with regard to surgeon's experience, there were no statistically significant differences. However, the mean time per LVA was significantly decreased as the experience increased over time (p = 0.017). CONCLUSION: LVA is an effective treatment option to reduce the volume in the affected limb and to improve symptoms involved. Regardless of the number and experience of the surgeons, cellulitis improves significantly after LVA. The experience of the surgeon does not significantly impact the positive outcome while proficiency increases with experience.

Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes.

BACKGROUND: Of all body regions, lower extremity wounds have been and remain the greatest challenge. Perforator free flaps have been accepted as a reasonable option to solve this dilemma but require the complexity of microsurgery. As a consequence, the possibility that pedicled perforator flaps could supplant even perforator free flaps has recently gained intense enthusiasm. METHODS: A retrospective investigation was undertaken to compare the validity for the use of perforator flaps of all types at three dissimilar institutions, that is, a university, a regional center, and a community hospital. All flaps performed in the 5-year period, 2011 to 2015, were included to allow at least 1-year follow-up before data analysis. A total of 433 free perforator flaps and 52 pedicled perforator flaps had been performed specifically for the lower extremity. RESULTS: Patient demographics, wound etiology, and comorbidities were similar for all institutions. Free flaps were more commonly needed after trauma and for chronic ulcers. Pedicled flaps were more likely an option after tumor excision. Large defects or those involving the foot were better served by free flaps. Overall success for free perforator flaps was 90.1% and for pedicled perforator flaps was 92.3%, with no significant difference noted (p = 0.606) between institutions. Peripheral vascular disease was the only significant comorbidity risk factor for both free and pedicled flap failure. CONCLUSION: Perforator flaps in general have become a reasonable solution for soft tissue defects of the lower extremity. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap could potentially be successful. Pedicled perforator flaps, if adequate healthy soft tissues remain adjacent to the defect, forecast a continuance of the evolution in seeking simplicity yet reliability by the best flap possible for soft tissue closure of the lower limb wound.

Innovations in diabetic foot reconstruction using supermicrosurgery.

The treatment of diabetic foot ulceration is complex with multiple factors involved, and it may often lead to limb amputation. Hence, a multidisciplinary approach is warranted to cover the spectrum of treatment for diabetic foot, but in complex wounds, surgical treatment is inevitable. Surgery may involve the decision to preserve the limb by reconstruction or to amputate it. Reconstruction involves preserving the limb with secure coverage. Local flaps usually are able to provide sufficient coverage for small or moderate sized wound, but for larger wounds, soft tissue coverage involves flaps that are distantly located from the wound. Reconstruction of distant flap usually involves microsurgery, and now, further innovative methods such as supermicrosurgery have further given complex wounds a better chance to be reconstructed and limbs salvaged. This article reviews the microsurgery involved in reconstruction and introduces the new method of supermicrosurgery.

Consideration in lower extremity reconstruction following oncologic surgery: Patient selection, surgical techniques, and outcomes.

The goal for reconstruction following oncologic surgery involves providing adequate coverage allowing subsequent adjuvant therapy, preserving function, and to have a reasonable aesthetic outcome. Patients with soft tissue tumors of the lower extremity have en bloc tumor resections with wide margins for local control followed by reconstruction. This reconstructive algorithm demonstrates survival rates equivalent to amputation, with success approaching 95%. Attempting limb salvage has now become the mainstay standard for reconstructing defects following excision of lower extremity cancers. J. Surg. Oncol. 2016;113:955-961. © 2016 Wiley Periodicals, Inc.

Do Skin Perforator Flaps Accommodate Foot Growth in Children after Reconstruction?

Backgrounds Whether or not the flap accommodates growth is unpredictable and remains to be determined. We hypothesized that perforator flaps may accommodate growth after reconstruction in children and evaluated change of the flap after foot and ankle reconstruction. Methods A retrospective review of 28 children from 2003 to 2015 was performed with children under 14 years of age who had foot and ankle soft tissue defects. The following evaluations were made: (1) comparing flap to foot growth, (2) comparing flap/foot dimension using the photo-anthropometric technique defined as proportionality index (PI), and (3) comparing PI ratio of flap to foot area at intervals (ΔPI). All values were measured and statistically evaluated by Pearson's correlation analysis and paired t-test. Subsequent complications and functional results were also evaluated. Result Foot and flap after growth had positive correlation in Pearson's correlation analysis, showing the flap expands as the foot grows. The mean intraoperative and postoperative PI was 0.3 and 0.2475, respectively, with statistical significance (ΔPI; p < 0.01). However, no patient had growth disturbance or functional impairment. There was no correlation between ΔPI and motor power grade or between ΔPI and range of motion (p > 0.01). Conclusion The skin perforator flap significantly expands during growth after reconstruction. Although the expansion of the flap to foot may not be a one-to-one ratio, it expands enough not to impair the growth or functional outcome of the foot. Skin perforator flap showed growth as children grow and can be considered as a reliable and feasible option in pediatric reconstructive surgery.

Survey of reconstructive microsurgery training in Korea.

BACKGROUND: Microsurgical technique in reconstructive surgery is important. Despite recognizing this fact, there are no systematized microsurgery training programs in Korea. The purpose of this study was to diagnose the current training programs and discuss the direction that is needed to improve them. METHODS: The authors conducted a survey of graduates of a plastic surgery residency program. The questionnaire included the volume of microsurgery, training environment, area of microsurgery, department(s) performing microsurgery, and the frequency with which flaps were used. RESULTS: Many specialties other than plastic surgery involved microsurgical procedures. The volume of microsurgery cases was disproportionate between large and small hospitals, creating an imbalance of residents' experience with microsurgical procedures. The increase in microsurgical procedures being performed has increased the number of surgeons who want to train in microsurgery. CONCLUSION: Increasing the number of microsurgery training programs will create more microsurgeons in Korea.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

BACKGROUND: The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. PATIENTS AND METHODS: From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. RESULTS: The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. CONCLUSION: Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk.

Soft Tissue Reconstruction After Revascularization.

Diabetic foot ulcer represents the primary cause of hospital admissions, amputations, and mortality in diabetic patients. The development of diabetic foot ulcers is influenced by peripheral neuropathy, infection, and ischemia, with diabetes contributing to peripheral artery disease. Free tissue transfer combined with revascularisation of the lower extremity provides the potential opportunity for limb salvage in individuals with lower extremity defects due to critical limb ischemia and diabetic foot.

Potential of Allogeneic Adipose-Derived Stem Cell-Hydrogel Complex for Treating Diabetic Foot Ulcers.

Mesenchymal stem cells (MSCs) may hold great promise for treating diabetic wounds. However, it is difficult for a clinician to use MSCs because they have not been commercialized. Meanwhile, a new commercial drug that contains adipose-derived stem cells (ASCs) has been developed. The purpose of this study was to examine the potential of allogeneic ASC sheets for treating diabetic foot ulcers. Fifty-nine patients with diabetic foot ulcers were randomized to either the ASC treatment group (n = 30) or a control group treated with polyurethane film (n = 29). Either an allogeneic ASC sheet or polyurethane film was applied on diabetic wounds weekly. These wounds were evaluated for a maximum of 12 weeks. Complete wound closure was achieved for 73% in the treatment group and 47% in the control group at week 8. Complete wound closure was achieved for 82% in the treatment group and 53% in the control group at week 12. The Kaplan-Meier median times to complete closure were 28.5 and 63.0 days for the treatment group and the control group, respectively. There were no serious adverse events related to allogeneic ASC treatment. Thus, allogeneic ASCs might be effective and safe to treat diabetic foot ulcers.

Thin elevation: A technique for achieving thin perforator flaps.

Elevating thin flaps has long been a goal of reconstructive surgeons. Thin flaps have numerous advantages in reconstruction. In this study, we present a surgical method for elevating a thin flap and demonstrate the safety of the procedure. A retrospective review was performed of the electronic medical records of patients who underwent thin flap elevation for lower extremity reconstruction from April 2016 to September 2016 at the Department of Plastic Surgery of Asan Medical Center. All flaps included in this study were elevated above the superficial fascia. A total of 15 superficial circumflex iliac artery free flaps and 13 anterolateral thigh free flaps were enrolled in the study. The total complication rate was 17.56% (n=5), with total loss of the flap in one patient (3.57%) and partial necrosis of the flap in four patients (14.28%). No wound dehiscence or graft loss at the donor wound took place. Elevation above the superficial fascia is not inferior in terms of flap necrosis risk and is superior for reducing donor site morbidity. In addition to its safety, it yields good aesthetic results.

Use of a helical composite free flap for alar defect reconstruction with a supermicrosurgical technique.

The highly contoured nature of the nose and the abundant free margin makes it especially difficult to reconstruct. In this report, we describe the use of a new helical rim free flap technique for the reconstruction of full-thickness nasal alar defects via supermicrosurgery. Briefly, after a wide excision with a margin of 0.7 cm, an alar defect with a size of 1×1×0.5cm was obtained, which included the full thickness of the skin, mucosa, and lower lateral cartilage. Vessel dissection was performed in a straightforward manner, starting from the incision margin for flap harvest, without any further dissection for reach the greater trunk of the superficial temporal artery. The flap was inset in order to match the contour of the contralateral ala. We closed the donor site via rotation and advancement. No donor site morbidity was observed, despite the presence of a small scar that could easily be covered with hair. The alar contour was satisfactory, and the patient was satisfied with the results. The supermicrosurgical technique did not require further dissection to identify the vessels for anastomosis, leading to better cosmetic outcomes and a reduced operating time.

The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis.

BACKGROUND: Treatment of chronic osteomyelitis involves aggressive débridement followed by soft-tissue coverage. The dictum of muscle coverage being superior has been challenged by successful reports of coverage with skin flaps. The objective of this article is to evaluate the efficacy of perforator flaps for reconstruction of chronic osteomyelitis defects. METHODS: A retrospective review of 120 patients with chronic osteomyelitis who underwent débridement and reconstruction using perforator flaps from April of 2000 to November of 2015 was conducted. Inclusion criteria were cases with chronic osteomyelitis for a minimum of 6 weeks and with a follow-up of at least 2 years after surgery. Correlation between recurrence and the following factors was analyzed: comorbidities, frequency of débridement, duration of chronic osteomyelitis, limb vascular status, and method of dead space obliteration. The outcomes analyzed were flap loss, recurrence rate, primary remission rate, secondary remission rate, and amputation rate. RESULTS: The flap loss rate was 4.2 percent flap, the recurrence rate was 8.3 percent, the primary remission rate was 91.6 percent, the secondary remission rate was 98.3 percent, and the amputation rate was 1 percent. Significant predictors of recurrence were peripheral vascular disease and major vessel compromise, which had 5.1 times higher odds of recurrence (p < 0.05). CONCLUSIONS: Used with adequate débridement, bone reconstruction, and obliteration of dead space, a primary remission rate of 91.6 percent and a secondary remission rate of 98.3 percent were achieved using perforator flap. The predictors of chronic osteomyelitis recurrence were peripheral vascular disease and major vascular compromise. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Study of the Medial Superficial Perforator of the Superficial Circumflex Iliac Artery Perforator Flap Using Computed Tomographic Angiography and Surgical Anatomy in 142 Patients.

BACKGROUND: The two major perforators supplying the superficial circumflex iliac artery perforator flap are the medial (superficial) and lateral (deep) perforators; however, they lack detailed description. The purpose of this study was to clarify the anatomy. METHODS: In a prospective analysis of 142 patients, computed tomographic angiograms of 284 superficial circumflex iliac artery perforator regions were evaluated, and 142 superficial circumflex iliac artery perforator flaps were surgically correlated. The origin of the superficial circumflex iliac artery, the origin of the medial perforator, the location where it penetrates the deep fascia, and its pattern of pathway after penetration of the superficial fascia were evaluated. RESULTS: There was 100 percent correlation between computed tomographic angiogram and surgical findings. The superficial circumflex iliac artery originates mostly from the femoral artery in 84.8 percent. The medial perforator originated from the superficial circumflex iliac artery in 94 percent. The medial perforator typically penetrated the deep fascia within an oval of 4.2 × 2 cm located 4.5 cm lateral and 1.5 cm superior from the pelvic tubercle. After passing the superficial fascia, the medial perforator either anchored directly into skin (56 percent) or traveled in an axial pattern (44 percent) beyond the anterior superior iliac spine. CONCLUSIONS: Despite the origin of the medial perforator, it was constantly observed penetrating the deep fascia. However, the pathway of the medial perforator can be either anchoring directly into the dermis or extending as an axial pattern artery, implicating a different effect on the survival of the flap. These new findings will allow better understanding for elevating the superficial circumflex iliac artery perforator flap based on the medial perforator.

Effects of Incisional Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study.

BACKGROUND: Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest. METHODS: This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled. RESULTS: There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group. CONCLUSION: The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A New Approach for Reconstruction of Diabetic Foot Wounds Using the Angiosome and Supermicrosurgery Concept.

BACKGROUND: Major vessels in the diabetic foot are often calcified and inadequate for use as recipient vessels. Thus, a supermicrosurgery technique using small branches or perforators from other collateral vessels with an adequate pulse may be an alternative method. This study evaluated outcome using the supermicrosurgery concept and the risk factors involved. METHODS: Ninety-five cases of diabetic foot reconstruction were reviewed; the average patient age was 57 years; average follow-up was 43.5 months. Débridement was performed according to the angiosome concept, and reconstruction was performed with perforator flaps using the supermicrosurgery approach. Correlation between total flap loss and 16 preoperative risk factors (age, sex, diabetes mellitus type, smoking, immunosuppression, flap size, hemoglobin A1c, ankle-brachial index, preoperative transcutaneous partial pressure of oxygen, C-reactive protein, computed tomographic angiography, amputation history, peripheral artery disease, American Society of Anesthesiologists physical status, osteomyelitis, and chronic renal failure) were analyzed. RESULTS: Of 95 cases, nine cases of total loss and 12 of minor complication were noted. Among the risk factors, the odds for failure after peripheral artery disease was 10.99 (p = 0.035), and that associated with a history of amputation was 9.44 (0.0006). Other factors had no correlation with flap loss, including cases with no or one major vessel. Flap survival rate was 90.5 percent, and the overall limb salvage rate was 93.7 percent. CONCLUSIONS: Despite the high risk of failure related to peripheral artery disease and history of amputation, the supermicrosurgery approach using a recipient vessel with good pulsation regardless of the source can achieve limb salvage. This approach extends the possibility for reconstruction in patients with severe ischemic diabetic foot. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Mobile Application for Wound Assessment and Treatment: Findings of a User Trial.

The D+Wound Solution is a mobile phone application (app) that assists users in the assessment and treatment of the wound. The app has 6 components for assessment: need for debridement, infection control, revascularization, and exudate control; whether it is chronic; and finally, the top surface of the skin. These components are named D.I.R.E.C.T. The app makes you review these components as an algorithm to provide a reasonable solution for dressing. It is designed to understand the status of the wound and provide a practical treatment idea for wound care providers. A total of 118 nurses were divided into 2 groups, designated as experienced and less-experienced groups, and surveyed. Both groups found the app to be helpful in making a treatment plan. However, the less-experienced group found it to be significantly more useful in assessing the wound ( P = .026) but difficult to understand the logic. The experienced group found the logic to be significantly easier to understand ( P = .018) and had significantly higher similarities ( P = .015) in treatment protocols compared with the less-experienced group. We may conclude that this app has a logical algorithm resembling experienced wound caregivers and is more useful in the less-experienced group.

Radiation Pneumonitis in Association with Internal Mammary Node Irradiation in Breast Cancer Patients: An Ancillary Result from the KROG 08-06 Study.

PURPOSE: The aim of this study is to present the incidence of radiation pneumonitis (RP) reported within 6 months after treatment for breast cancer with or without internal mammary node irradiation (IMNI). METHODS: In the Korean Radiation Oncology Group (KROG) 08-06 phase III randomized trial, patients who were node-positive after surgery were randomly assigned to receive radiotherapy either with or without IMNI. A total of 747 patients were enrolled, and three-dimensional treatment planning with computed tomography simulation was performed for all patients. Of the 747 patients, 722 underwent chest X-rays before and within 6 months after radiotherapy. These 722 patients underwent evaluation, and RP was diagnosed on the basis of chest radiography findings and clinical symptoms. The relationship between the incidence of RP and clinical/dosimetric parameters was analyzed. RESULTS: RP developed in 35 patients (4.8%), including grade 1 RP in 26 patients (3.6%), grade 2 RP in nine patients (1.2%); there was no incidence of grade 3 or higher RP. Grade 2 RP cases were observed in only the IMNI group. The risk of developing RP was influenced by IMNI treatment; pneumonitis occurred in 6.5% of patients (n=23/356) who underwent IMNI and in 3.3% of patients (n=12/366) who did not (p=0.047). The differences in lung dosimetric parameters (mean lung dose, V10-40) were statistically significant between the two groups. CONCLUSION: IMNI treatment resulted in increased radiation exposure to the lung and a higher rate of RP, but the incidence and severity of RP was minimal and acceptable. This minor impact on morbidity should be balanced with the impact on survival outcome in future analyses.

Using a Contradictory Approach to Treat a Wound Induced by Hematoma in a Patient With Antiphospholipid Antibody Syndrome Using Negative Pressure Wound Therapy: Lessons Learnt.

A 48-year-old woman with antiphospholipid syndrome (APS) had multiple skin necrosis caused by massive bleeding and hematoma collection at the right lower leg, left thigh, and abdomen. During the first month, we did surgical debridement every 2 to 3 days with meticulous coagulation and applied negative pressure wound therapy (NPWT). Then as the base showed initial granulation, we changed the NPWT every 4 days. NPWT was used with lower pressure and cyclic mode (-40 to -75 mm Hg) to minimize trauma and to reduce the possibility of bleeding from the wounds. After 2 months of NPWT treatment, all the wounds eventually healed with secondary intension despite the patient's condition with diabetes, hemodialysis, anticoagulant use, and corticosteroid therapy. This report supports the idea that if accompanied by conservative debridement with meticulous bleeding control, application of NPWT in low pressures and close monitoring of the patient, NPWT is possible to use even in wounds of patients with risk for bleeding.